Facility Evaluation Report

Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with administrator Debbie McCulloch. Some clients were present at the facility. Some clients at this facility have their own activities during the day and/or are working. There are activities planned for clients during the day if they want to participate.

LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 6/13/2022 with administrator Debbie McCulloch facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Sample of client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 6/2021 at the time of the visit. Carbon monoxide detector was operational during visit. Sample test of Smoke detectors was conducted and were operational during this visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked closet in the living room, however; during tour of facility LPA observed several unlocked toxins under clients’ bathrooms under sink. (see pictures, LIC 809-D). Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. Client’s bedrooms that were inspected had lighting & appropriate furnishings; mattress pads are available for clients at the facility. Facility hot water temperature in clients' bathroom faucets measured between 113.3 degrees F and 150.8 degrees F in 1 out of 3 faucets falling out of Title 22 acceptable regulations of 105 to 120 degrees F. Client’s bathroom in the annex part of facility had a faucet with hot water temperature of 150.8 degrees F. (see LIC 809-D) Disaster Drills have been conducted often with the last one being conducted on 2/23/2022.